title: Management of lower urinary tract dysfunction: a stepwise approach.
abstract: OBJECTIVE
  To evaluate management patterns of lower urinary tract (LUT) dysfunction and establish a treatment algorithm to guide pediatric healthcare providers.
  
  
  METHODS
  390 children with non-neurogenic LUT dysfunction were followed over 7 months; 115 patients were excluded due to incomplete data. Children were categorized based on presenting complaints and pelvic ultrasound into three groups: daytime urinary incontinence (UI) with complete emptying (CE), UI with incomplete emptying (IE), or IE without UI. Every child underwent behavioral modification (BM) including timed voiding, double voiding, deep breathing, and treatment of constipation if present. BM failures received secondary treatment including medications (alpha blockers, anticholinergics), physical therapy, and/or botulinum toxin type A injection of the external sphincter at a dose of 100 units.
  
  
  RESULTS
  BM improved symptoms in 152 (55%): 68% (46% dry), 49% (27% dry), and 59% (29% dry) from the three groups, respectively. Of the 45% who showed no change in symptoms, 98 (80%) improved with addition of medication, the majority (89) after starting alpha blocker therapy. Children with IE responded better to alpha blockers, 83 (77%) compared to 38% with CE, whereas those with CE demonstrated more symptom resolution with anticholinergics, 6 (38%) compared to 13% of those with IE. Only 6 (2%) patients were refractory to non-operative treatment with all showing improvement after injection of botulinum toxin type A, 4 (67%) of whom became completely dry.
  
  
  CONCLUSIONS
  Diagnosis of UI and/or IE with stratification of children into particular symptom groups appears beneficial in determining the appropriate therapy for children with LUT dysfunction.
authors.affiliation: Pediatric Urology, Washington University in St Louis, St. Louis Children's Hospital, 4990 Children's Place, Suite 1120, Box 8242, St. Louis, MO 63110, USA. thomm@wudosis.wustl.edu
authors.forename: Matthew
authors.initials: M
authors.lastname: Thom
authors.forename: Mary
authors.initials: M
authors.lastname: Campigotto
authors.forename: Vijaya
authors.initials: V
authors.lastname: Vemulakonda
authors.forename: Douglas
authors.initials: D
authors.lastname: Coplen
authors.forename: Paul F
authors.initials: PF
authors.lastname: Austin
mesh_terms: D000293:Adolescent; D000367:Age Factors; D001521:Behavior Therapy / Q000379:methods; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003131:Combined Modality Therapy; D003558:Cystoscopy / Q000379:methods; D016208:Databases, Factual; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015552:Injections, Intralesional; D059411:Lower Urinary Tract Symptoms / Q000175:diagnosis / Q000628:therapy; D008297:Male; D026741:Physical Therapy Modalities; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors; D016896:Treatment Outcome; D014549:Urinary Incontinence / Q000175:diagnosis / Q000628:therapy*; D016055:Urinary Retention / Q000175:diagnosis / Q000628:therapy*; D014563:Urodynamics
chemical_list: D019274:Botulinum Toxins, Type A